Healthcare Provider Details

I. General information

NPI: 1295387918
Provider Name (Legal Business Name): SOUTHERN PALM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2019
Last Update Date: 07/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1472 BOLGER AVE
SPRING HILL FL
34609-6107
US

IV. Provider business mailing address

1472 BOLGER AVE
SPRING HILL FL
34609-6107
US

V. Phone/Fax

Practice location:
  • Phone: 352-600-8095
  • Fax: 352-796-5262
Mailing address:
  • Phone: 352-600-8095
  • Fax: 352-796-5262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. MATTHEW SUTERS
Title or Position: ADMINISTRATION
Credential:
Phone: 850-559-2543